'R' Power: Raising Lower Lid Rejuvenation To The Power Of R In Five Systematic Steps

by Linda Marie Wetzel

Published Jul 1, 2008 in the Cosmetic Surgery Times

Key Points

  • A conceptual five-step approach describes the categories of challenges that must be addressed when rejuvenating the lower eyelids
  • This approach also provides guidelines for determining the best options for individualized treatment.

In lower eyelid rejuvenation, careful attention to a series of specific steps will assure that each patient’s individual needs are being effectively addressed, says one expert.

“I came up with the five R’s to make it easy to remember that there are multiple things that must be considered when talking about rejuvenating eyelids,” explains Nancy Swartz, M.S, M.D., F.A.C.S. Dr. Swartz is a fellow of the American Academy of Ophthalmology and the American Academy of Cosmetic Surgery (AACS), and serves on the teaching staff of Wills Eye Hospital and the University of Pennsylvania School of Medicine. She presented details of her approach at this year’s annual AACS meeting in Orlando, Fla.

‘R’EMOVE In this case, “removal” refers to excess fat or skin from the lower eyelid area. Historically, lower lid rejuvenation consisted mostly of various excision techniques aimed at reducing the amount of tissue in this area. According to Dr. Swartz, there is a place for these procedures but, in general, they are overused.

“Excess skin is less of a problem than people think, and removal of tissue can be overdone,” Dr. Swartz says. “I believe that, in rejuvenation, it’s often a better idea to consider steps other than excision.”‘R’EINFORCE “Reinforcing” consists of repairing structural defects in the lower lids. The major structural defect is laxity, the presence of which can be documented in several ways according to Dr. Swartz.

Using the distraction test, the lower lid is grasped and pulled away from the globe. If the tissue can be pulled 7 mm or further, then horizontal laxity is present. In a second assay for skin tone, the snapback test, the lower lid is pulled down as the patient is instructed not to blink. If the lid does not quickly pop back to position, or if the patient must blink to restore the lid to normal position, the lower eyelid is considered to have poor tone.

Tightening the lower eyelid horizontally usually involves reinforcing the lateral canthal tendon via canthoplasty or canthopexy. When the presence of lax tendons is compounded by both loose skin and loose orbicularis muscle, Dr. Swartz also performs a redraping of the orbicularis muscle.

“We don’t just excise the extra skin and orbicularis muscle, but we must support what’s there,” Dr. Swartz tells Cosmetic Surgery Times. “In addition to tightening the tendon, what I tend to do is attach the orbicularis muscle to the periosteum of the orbital rim laterally so that the muscle is well supported. This reduces the likelihood that the patient will develop lower eyelid retraction post-operatively.”


These terms describe “resurfacing” the eyelid skin and “relaxing” the muscles to reduce dynamic wrinkles and reshape the eyelids.

“Removing skin does not improve the quality of what’s left,” Dr. Swartz explains. “Wrinkles don’t go away because you remove skin. You have to directly address the skin itself.”

The choice of CO2 lasers, chemical peels or fillers depends on the patient – the specific needs of the skin as well as lifestyle issues. For example, laser resurfacing results in skin erythema that may persist for weeks or months. In circumstances in which this is not acceptable to the patient, Dr. Swartz prefers using hyaluronic acid fillers to tighten the lower lid skin.

Use of neuromodulators such as Botox (botulinum toxin type A; Allergan, Irvine, Calif.) is an established treatment option for wrinkle correction around the eyes. But, she explains, a small injection of Botox into the central aspect of the pretarsal orbicularis can diminish the appearance of a hypertrophic orbicularis muscle, or “orbicularis roll,” that appears under the eyes of patients when they smile. And injecting Botox into the pretarsal orbicularis at the lateral canthal angle can increase the aperture of the eye, particularly when the patient smiles.

Dr. Swartz warns that careful placement is the key to achieving successful results. Botox injected too deeply inside the orbital rim (underneath the septum) may affect the extraocular muscles, resulting in double vision; deep injections outside the orbital rim can affect muscles that elevate the lip, resulting in a crooked smile. If the medial orbicularis muscle is weakened, tear drainage can be compromised.

‘R’EFILL Hyaluronic fillers such as Restylane (Q-Med, Uppsala, Sweden) and Juvéderm (Allergan) are the components of the final R – “refilling,” or correcting deflation of the lower eyelid and the orbit.

“Most of the aging in the lower lid results from losing volume, and as the skin and subcutaneous fat thins, we uncover the hills and valleys of the structures underneath,” Dr. Swartz notes. “In reality, what’s there has always been there, but we’ve just lost the fullness that created those large smooth curves of the face that we had in youth.”

To contour the lower eyelid and fill the area of volume loss, Dr. Swartz injects Restylane deeply, just above the periosteum. Because Juvéderm causes some patients to experience fluid buildup which may distort the appearance of the lower lid, Dr. Swartz does not use it for contouring; however, she does use Juvéderm to correct issues with skin quality. The injection of microscopic droplets just beneath the epidermis gives the skin more thickness and turgor. Dr. Swartz prefers these products, not only because they stimulate the production of natural collagen in the skin, but because particulates in other types of fillers could result in an embolus to the retina and subsequent loss of vision.

Dr. Swartz also reminds cosmetic practitioners that a dilute hyaluronidase solution may be used to reverse the effects of excess amounts of hyaluronic acid filler. “Just inject a little under the surface of the skin where it will thin the filler a little and make it easier to smooth out an area or move it to another place,” Dr. Swartz says.

“Everyone’s eyelids are different and everyone has different issues,” Dr. Swartz says. “The five R’s are a conceptual way of categorizing the types of problems that can happen with the eyelids we want to rejuvenate.”

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